US5499996A - Blood vessel occlusion trocar - Google Patents

Abstract

Apparatus in the form of a trocar adapted for penetration of the wall of a blood vessel, such as the ascending aorta, contains an inflatable diaphragm carried in a collapsed condition within the interior of the trocar and an appropriate fluid connection of the diaphragm to a source of inflating fluid effects the expansion of the diaphragm and release from the trocar into occluding relation with the blood vessel wall to obstruct the flow of blood through the occluded passage. The interior of the described trocar is divided into separate fluid conducting passages which, via the provision of appropriately placed openings in the wall of the shell forming the trocar, enables the performance of a multitude of procedures attendant with cardiac surgery by way of a single incision made in the wall of the aorta, such procedures including aortic arterial perfusion in conjunction with heart-lung machine operation; admission of myocardial preservation solution; aortic root pressure measurement and venting and clearing of the heart and aortic root. The invention contemplates use with the apparatus of a pressurizing belt containing an expandable cuff whose operation is coincident with that of the occluder diaphragm to prevent distention of the blood vessel wall and the prospective dangerous conditions resulting therefrom.

Description

This application is a division of application Ser. No. 07,808,767, filed Dec. 17, 1991, now U.S. Pat. No. 5,339,498.

BACKGROUND OF THE INVENTION

This invention relates to cardiovascular surgical apparatus. More particularly, the invention relates to apparatus, a principle function of which is to more safely occlude the ascending aorta during the performance of open-heart surgery.

In many surgical procedures it is necessary to occlude a blood vessel in order to provide the surgeon with a bloodless field in which to work. Such occlusion is most commonly effected by the application of a vascular clamp to the concerned region of the blood vessel. In the performance of most open heart surgical procedures where occlusion of the ascending aorta is essential, however, the use of a vascular clamp for clamping this vessel creates a condition susceptible to serious negative consequences that the surgeon cannot completely control. For example, while the use of a vascular clamp to occlude the aorta provides a quick and easy occlusion of the vessel, clamping the aorta can disrupt the aortic wall, thereby dislodging degenerative plaque-like material, which is capable of migrating to the brain thereby resulting in a stroke. Other consequences can also result from clamping the aorta. For example, the dislodged particles may migrate to other parts of the body thereby creating the danger of limb gangrene in the extremities, such as the arms or legs, or damage to certain organs as, for example, the kidney, the liver or the small or large bowel. Alternatively, in clamping the aorta, the wall may rupture thereby resulting in hemorrhage. Each of these complications can cause serious morbidity and oftentimes may result in death.

It is to the amelioration of these problems, therefore, to which the present invention is directed.

SUMMARY OF THE INVENTION

In accordance with a principle aspect of the present invention there is provided an occluder apparatus for obstructing the flow of blood in a blood vessel comprising an elongated hollow tubular body having a leading end sized for reception in said blood vessel, means for inserting said body through the wall of said blood vessel to extend said leading end into the interior of said blood vessel, an inflatable diaphragm carried in a collapsed, deflated condition within the interior of said body, means for conducting an inflating fluid from an external source into fluid communication with the interior of said diaphragm to effect expansion thereof, means in said body to enable release of said diaphragm in an inflated state from said body into flexible occluding engagement with the interior wall of said blood vessel about substantially the full circumference of a section thereof.

The invention contemplates use with the described occluder device of an external belt-like blood vessel wall-compressing device adapted to surround the blood vessel and apply a compressive force in opposed relation to the force applied by the occluder diaphragm. By use of the belt-like compressing device the blood vessel can be effectively occluded by the diaphragm without distention or distortion of the wall thereof thus to prevent flexure of the wall and dislodgement therefrom of fragile material that could create a dangerous condition in the patient.

Apparatus according to the invention can be particularly designed to facilitate several procedures common to open-heart surgery. For example, besides obstructing the flow of blood to the heart to create a quiescent region within which the surgeon can work, the apparatus can be designed to be useful in the introduction of myocardial preservation solution to the proximal region of the aorta. On the other hand, the passage designed to conduct myocardial solution can, alternatively, be connected to a pressure measuring device for monitoring aortic root pressure. Similarly, the passage can be employed for venting the aortic root and/or clearing the heart and aortic root of blood and/or air. Importantly, the apparatus can also be made to perform as an aortic arterial perfusion cannula for circulating blood between a heart-lung machine and the patient in bypass relation to the occluded region of the aorta and the heart.

It is, accordingly, an object of the invention to provide an improved apparatus for occluding blood flow in blood vessels in selected body sites, particularly in the ascending aorta, to facilitate surgical procedures.

It is another object of the invention to provide an effective blood vessel occluder in which the danger of dislodging brittle material from the wall of the blood vessel and the concomitant danger of creating serious morbidity is minimized.

Yet another object of the invention is to provide apparatus that permits the performance of multiple surgical functions and procedures through a single incision made in the blood vessel thereby eliminating the need to make plural incisions in the blood vessel commensurate with the number of procedures to be performed.

For a better understanding of the invention, its operating advantages and the specific objectives obtained by its use, reference is made to the accompanying drawings and description which relate to preferred embodiments of the invention.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 is a perspective representation, partly schematic, of an occluder apparatus operatively associated with a pressurizing belt according to the invention;

FIG. 2 is a perspective representation of the occluder apparatus according to the invention FIG. 2a is a view similar to FIG. 2, illustrating a structure to which the passage means may be connected when the occluder apparatus is used with a source of myocardial fluid or a pressure monitor, or both; FIG. 2b is a partial sectional view of the occluder apparatus of FIG. 2a, illustrating a structure to which the passage means may be connected when the occluder apparatus is used with a heart-lung machine in a preliminary stage of installation;

FIG. 3 is a perspective representation of the occluder apparatus according to the invention in an intermediate stage of installation;

FIGS. 4 through 6 illustrate an embodiment of the invention in various operative stages when installed in a blood vessel.

FIG. 7 is a sectional view of the occluder apparatus and pressurizing belt taken along line 7--7 of FIG. 6.

FIG. 8 is a sectional elevational view a trocar body carrying an occluder diaphragm in its deflated condition;

FIG. 9 is a cross-sectional view taken along line 9--9 of FIG. 8;

FIG. 10 is a view of the diaphragm mounting plate with the diaphragm removed;

FIG. 11 is a view illustrating the diaphragm in an inflated condition;

FIG. 12 is a plan view of a pressurizing belt according to the invention;

FIG. 13 is a sectional view taken alongline 13--13 of FIG. 12;

FIG. 14 is a view, similar to FIG. 1, illustrating another embodiment of the occluder apparatus and pressurizing belt according to the present invention;

FIG. 15 is a sectional view illustrating the occluder apparatus of FIG. 14 in operative position within a blood vessel;

FIG. 16 is a partial sectional view taken perpendicularly of FIG. 15;

FIG. 17 is a sectional elevational view of a trocar body as shown in FIG. 14 carrying an occluder diaphragm in its deflated condition;

FIG. 18 is a sectional view taken alonglines 18--18 of FIG. 17;

FIG. 19 is an elevational view of the trocar of FIG. 14 as viewed from the distal side;

FIG. 20 is an elevational view of the trocar as viewed from a lateral side;

FIG. 21 is an elevational view of the trocar as viewed from the proximal side;

FIGS. 22 and 23 are views similar to FIG. 21 illustrating the trocar of FIG. 14 in various stages of installation;

FIG. 24 is a plan view of an alternate form of pressurizing belt according to the invention;

FIG. 25 is a sectional view taken alongline 25--25 of FIG. 24; and

FIG. 26 is an elevational view of the pressurizing belt of FIG. 12 in operative position on a blood vessel.

DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS

Referring particularly to FIG. 1 there is shown a blood vessel occluder apparatus, indicated generally at 10, comprising an elongatedtubular trocar 12 which is held in its operative position by pressurizingbelt 14 in ablood vessel 16, here shown as the ascending aorta connecting with theheart muscle 18. The details of construction of thetrocar 12 are best shown in FIG. 8 as comprising an elongated, hollow, generally cylindricaltubular shell 20 formed of a relatively hard plastic material, such as a polycarbonate material, that is open at both its upper and lower ends, 22 and 24 respectively. The opening at theupper end 22 of theshell 20 is closed by aclosure cap 26 having openings therein to permit passage of fluid-conducting members, as hereinafter described. The opening at thelower end 24 ofshell 20 is of slightly smaller diameter than that of theinternal wall surface 28 of the shell, being defined by an inturnedflange 30 forming a substantiallyannular shoulder 32 about the opening.

Anannular flange 34 extends radially outwardly from the exterior surface of theshell 20 at an intermediate location along the length thereof. Theflange 34 is adapted to receive sutures 36 (FIG. 3) for fixedly attaching thetrocar 12 in position on the wall of the blood vessel.

Locking detents 38 formed of slightly compressible material are bonded to the shell surface and project radially outwardly from opposite sides thereof at a level about midway between theflange 34 and theupper end 22 of the shell. In the preferred embodiment of the invention, thesedetents 38 cooperate with locking means in thepressurizing belt 14, as hereinafter described, for establishing the positional relationship between thetrocar 12 and thebelt 14 prior to operation of theoccluder apparatus 10 according to the invention.

As shown in FIGS. 8 and 9 the interior of thetubular shell 20 forming thetrocar 12 is divided longitudinally by apartition plate 40 into transversely spaced regions indicated by thenumerals 42 and 44, respectively. Theplate 40, as shown best in FIG. 9, extends chordally across the interior ofshell 20 and has its opposite side edges sealedly attached tointernal wall surface 28. The lower end ofpartition plate 40 is spaced upwardly from thelower end 24 of theshell 20 and attaches aclosure plate 46 to defineregion 42 as a fluid conducting passage. A flow opening 48, which may be an enlarged solitary opening in the wall ofshell 20 or, as shown, formed of a plurality ofsmall diameter openings 49 extending therethrough, effects fluid communication between thepassage 42 and the exterior of thetrocar 12. Aline 50 extends through theclosure cap 26 and fluidly connects the other end of thepassage 42 to a fluid source, as for example a source of myocardial preservation solution, on the exterior of the trocar. See FIG. 2a.

In the described apparatus, thepassage 42 can, during alternate periods of operation, be employed to establish fluid communication between the interior of theblood vessel 16 and a pressure monitor (not shown) via theopening 48 and aflow line 51 that, at one end, extends through thecap 26 to communicate with thepassage 42 and, at the other end, connects with the pressure monitor. See FIG. 2a.

A secondchordally extending plate 52 extends across the interior of theshell 20 parallel to, but slightly spaced from, theplate 40. Theplate 52 contains a plurality of small diameter through-openings 53, typical examples of which are shown in FIGS. 10 and 11, and on its surface facing theinterior region 44 of thetrocar body 12 mounts anexpandable occluder diaphragm 54 formed of thin walled, flexible material, such as polyeurathane. The space betweenplates 40 and 52 contains a pair ofconductors 56 extending downwardly from a manifold 58 that mounts a fluid-conductingtube 60 for conducting saline activating fluid to the interior of thediaphragm 54 for inflating and expanding it into its operative condition. Flow distribution between theopenings 53 inpartition plate 52 and respective regions of thediaphragm 54 is effected bysmall diameter passages 55 that extend between theopenings 53 andsimilar openings 57 in the diaphragm wall.

In its expanded condition thediaphragm 54 assumes a shape corresponding essentially to that illustrated in FIGS. 6, 7 and 11 comprising a generally toroidally-shapedcushion portion 62 and amembrane portion 64 that fills the region of the diaphragm interiorly of the cushion portion. Upon inflation with saline fluid thediaphragm 54 is permitted to expand exteriorly of thetrocar 12 by means of a pair of aligned, oppositely spacedslots 66 that extend upwardly from the open lower end of theshell 20. Theslots 66 are so positioned in theshell 20 with respect to thediaphragm 54 in its deflated condition to enable it to readily project laterally outwardly into engagement with theinterior wall 68 of theblood vessel 16. Thus, when expanded, thediaphragm 54 effectively occludes flow through theblood vessel 16 with theopening 48 inshell 20 being disposed in facing relation to the proximal side of the apparatus.

Theapparatus 10 contains anexpandable penetrating plug 70 that, when expanded, is conical in shape. Thebase 72 ofplug 70 has a peripheral diameter permitting its engagement with theshoulder 32 formed at the lower end ofshell 20. The apex 74 of theplug 70 extends axially outwardly from the openlower end 24 of thetrocar body 12 to form a pointed tip suitable for penetrating the wall of theblood vessel 16 to permit insertion therein of the lower portion of the trocar after an incision has been made in the blood vessel wall.

Theplug 70 is hollow and has walls formed of an expandable flexible material, such as polyeurathane. A substantially rigid,elongated tube 76 attaches at its lower end to thebase 72 of theplug 70 with the passage through the tube in fluid communication with the hollow interior of the plug. The upper end of thetube 76 extends through a self-sealing opening in thecap 26 to connect with an exterior source of saline fluid.

In practice, thetrocar 12 is inserted radially through the wall of theblood vessel 16 by the surgeon's first making an incision 80 (FIG. 2) therein of an extent sufficient to permit insertion of theshell 20. The incision will be of such extent as to create an opening in the blood vessel wall of such an extent as to cause theshell 20 to be snugly received therein. (In preparation for closing the opening formed by theincisions 80, the surgeon may install a purse-string suture 81 about the opening). Thereafter, assisted by the piercing tip formed by the expandedplug 70, the trocar is caused to penetrate the blood vessel under the impetus of a downwardly-directed manual force applied to thetrocar 12. The extent of insertion of the trocar into the interior of theblood vessel 16 is limited by theflange 34 which, when placed in engagement with the exterior surface of the wall of the blood vessel, will locate thetip 74 of the plug at, or closely spaced from, the blood vessel wall opposite theincision 80.

Next, by properly aligning the trocar with the longitudinal axis of theblood vessel 16, as by means of guide marks (not shown) on the surface of theflange 34, proper disposition of the trocar can be determined such that theelongated slots 66 are aligned transversely across the blood vessel section.Sutures 36 are then applied viaopenings 35 formed in theflange 34 to securely attach the flange to the wall of theblood vessel 16.

Following this step, the fluid employed to expand theplug 70 is released therefrom by venting the fluid through thetube 76. Upon collapse of the plug walls, thetube 76 is withdrawn through a self-sealing opening in thecap 26 that accommodates passage of the collapsed plug.

With thetrocar 12 thus installed in theblood vessel 16 the more basic functions contemplated for theoccluder apparatus 10 can be achieved. For example, when inflating fluid, such as saline liquid, is admitted at pressures controlled by a valve (not shown) provided in theline 60, the fluid flows intomanifold 58 and through theconductors 56 and theopenings 53 in thepartition plate 52 into thecollapsed diaphragm 54, inflation will occur whereby the diaphragm will be caused to expand, with expansion beyond the confines of theshell 20 being permitted by means of the laterally facing openings therein created by theelongated slots 66. In expanding, the outer peripheral edge of the toroidally-shapedcushion portion 62 of thediaphragm 54 is, as best shown in FIGS. 6 and 7, caused to engage theinner wall surface 68 of theblood vessel 16 about substantially the entire circumference thereof. The material of which the diaphragm is constructed being of thin, light weight construction, and the pressure of the inflating fluid being appropriately controlled, thecushion portion 62 of the diaphragm is caused to closely envelop the shell body while conforming to the blood vessel wall tissue surface configuration so that an effective blood flow-occluding obstruction is effected in theblood vessel 16 without significant distention or description of the blood vesel wall.

Where the describedapparatus 10 is employed for aortic occlusion, with the patient effectively connected to a heart-lung machine in a manner well known in the surgical arts, it will be appreciated that, as well as providing the surgeon with a quiet, bloodless field on the proximal side of the occlusion within which to operate, the apparatus permits the practice of other procedures, as well. See FIG. 2b. For example, withline 50 connected to a source of myocardial preservation solution or blood cardioplegia, by periodic operation of a control valve (not shown) this solution can be supplied intermittently throughpassage 42 and exiting the trocar through theholes 49 formingopening 48 to the root of the aorta for perfusion through the coronary arteries into theheart muscle 18 to preserve and arrest the heart, thereby to facilitate the performance of a surgical procedure.

Also, during periods in which theline 50 is not employed for the supply of myocardial preservation fluid, it can be conveniently employed, by means of a suitable bypass connection containing valving to an evacuation pump (not shown), for removing blood from the heart via the aorta root thereby preventing the accumulation of blood in the heart and maintaining the heart in a collapsed condition whereby the practice of a surgical procedure on the heart can be facilitated.

Furthermore, the bypass connection attached by way ofline 50 toapparatus 10 can also be employed, during the occlusion period or following completion of the surgical procedure on the heart and deflation of the occluder, for the evacuation of any air bubbles from the heart chambers and the ascending aorta.

Still further, with theopening 48 in thetrocar shell wall 20 positioned closely adjacent thewall surface 68 in the upper region of the aorta passage, theline 50 can be effectively employed as a vent for removing air bubbles in the blood as it is pumped into the ascending aorta from the heart upon collapse of theoccluder diaphragm 54 when expansion fluid is released from theline 60 and the heart resumes its contraction. Use of theoccluder apparatus 10 for this purpose is most advantageous because the protrusion of the trocar into the aorta will create turbulence in the blood flow and the presence of the collapseddiaphragm 54 in the blood flow passage will tend to partially obstruct and retard the blood flow in this region and the entrained air bubbles will migrate upwardly whereby there evacuation through theopening 48 is enhanced.

Notwithstanding the capability of utility of theapparatus 10 in the above described manner, in its preferred mode of operation, the apparatus will be used in association with a pressurizingbelt 14, the details of construction of the embodiment of FIG. 1 of which are best illustrated in FIGS. 12 and 13 herein. Accordingly, thebelt 14 comprises a base 86 containing anupstanding collar 88 having a through-opening 90 that permits passage of thetrocar 12. Thebase 86 is generally C-shaped and defineswings 92 on opposite sides of thecollar 88 to form a strap-like structure.Openings 93 adjacent the terminal ends of thewings 92 are adapted to receive sutures for securing the wings to the blood vessel. Thebase 86 is formed of a plastic material, such as a polycarbonate material, having sufficient rigidity to impart strength to the construction, yet being sufficiently flexible to permit thewings 92 to flex, thereby enabling them to enclose theblood vessel 16 without distortion thereof, upon manual manipulation of operatingtabs 94 that are integrally formed on or bonded to the respective wings. The undersurface of the base 86 which, in operation, faces the exterior of theblood vessel 16 has attached thereto by means of bonding, or the like, aninflatable cuff 96 formed of soft, pliable material. An inflatingfluid inlet 98 is formed on one of thewings 92 and contains a passage that communicates with the interior of thecuff 96 whereby an inflating fluid can be supplied or released in order to expand or retract the cuff into and out of compressing relation with theenclosed blood vessel 16.

As shown, theopening 90 incollar 88 is formed along its wall withopposed channels 100, at the top of both of which is formed a cup-shapedrecess 102. These structural elements cooperate with thedetents 38 on the external surface of thetrocar shell 20 to positionally fix thetrocar 12 with respect to thebelt 14 and thereby establish the transverse disposition of theslots 66 in the shell with respect to the blood vessel section.

In the described embodiment of the invention, after thetrocar 12 is sutured to theblood vessel 16, the pressurizingbolt 14 is mounted thereon with thecollar 88 telescopically received on the upper portion of thetrocar shell 20 that projects from the blood vessel wall. As thecollar 88 is slid into position theopposed detents 38, which are of compressible material, slidingly engage thechannels 100 where they are compressed. Upon reaching the cup-shapedrecesses 102 thedetents 38 expand into the recesses to lockingly set the positional relationship between thetrocar 12, the pressurizingbelt 14 and theblood vessel 16.

Importantly, as best shown in FIG. 6, upon completion of the assembly of the pressurizingbelt 14 and thetrocar 12, thecuff 96 on the belt is disposed on the opposite side of the wall ofblood vessel 16 from theoccluder cushion 62. In the preferred practice of the invention, theline 60 that supplies saline liquid for expanding thediaphragm 54 is connected in parallel with theinlet 98 to thecuff 96 on the pressurizingbelt 14. Thus, the expansion fluid is admitted simultaneously to both theoccluder diaphragm 54 and to thecuff 96 so that occlusion of the blood vessel flow passage is accomplished without danger of either compression or distention of the wall thereof. Moreover, because the material that forms both thecushion 62 of thediaphragm 54 and thecuff 96 on thebelt 14 is soft and pliable and thereby readily conformable to the blood vessel wall structure, it will be appreciated that upon expansion of these members occlusion is accomplished without danger of dislodging fragile material or brittle tissue from the wall of the blood vessel or of squeezing atherosclerotic material into the vessel passage.

FIGS. 14 to 23 illustrate another trocar organization 12' which is constructed according to the invention and FIGS. 24 to 26 illustrate an alternate form of pressurizing belt 14' employing a collar 88' which is particularly adapted for use with the trocar organization of FIGS. 12 to 23 but whose base portion 86' can be used interchangeably with that of thebelt 14.

With reference to FIG. 14, which is a view similar to FIG. 1, there is illustrated a modified form of trocar 12' operably assembled with the modified form of pressurizing belt 14' and applied to an ascendingaorta 16 connected withheart muscle 18. In the practice of this form of the invention, the pressurizing belt 14' is first applied to the walls of theblood vessel 16 and thereafter the trocar 12', equipped with scalpel blades 146 (FIG. 17), as hereinafter described, incises the wall of theblood vessel 16 as the trocar is extended into the belt collar 88'. The construction of the trocar 12', moreover, is such as to permit, besides the functions described for the embodiment of FIGS. 1 to 11, the additional functions of operation of an aortic arterial perfusion cannula for circulation of blood between the patient and a heart-lung machine, with all such functions being achieved form a single incision made in the aorta wall upon application of the trocar into the collar 88' of the pressurizing belt 14'.

Accordingly, as best shown in FIG. 17, the trocar 12' comprises a generally tubular shell 20', the wall of which is formed intermediate its upper and lower ends with anannular shoulder 106 that divides the shell into a larger diameterupper portion 108 and a reduced diameterlower portion 110.Shoulder 106 operates to limit the extent of penetration of the trocar into the aorta passage.

The upper end of the shell 20' is closed by a closure cap 26' having a single opening formed with self-sealing capability to permit passage of ablade assembly 144 along the shell axis and retractive withdrawal of the blade assembly at an appropriate point in the operational procedure of the apparatus, as hereinafter described. As shown, the trocar shell 20' is provided in thelower portion 110 with laterally aligned elongated slots 66' extending upwardly from the lower end of the shell to permit egress of theoccluder diaphragm 54 upon application of the inflating fluid thereto.

Thelower portion 110 of the shell 20' is provided on one side of the slots 66' with a discharge opening 48', here shown as a plurality of small diameter holes 49', for communicating an internal passage 42' formed by a chordally disposedplate 116 and acover plate 118 with the proximal side of the trocar 12'. The passage 42' contains two sources of communication with the exterior. The first, comprising aninlet connection 119 in the shell wall and an abbreviated fluid line orelbow 120 that fluidly connects theconnection 119 with the interior of the passage 42', serves to supply myocardial preservation solution to the aorta, in a manner as previously described, when the trocar is operably installed in the aorta. By means of asecond fluid connection 122 communicating with the passage 42' the trocar can also be connected to a pressure monitor device (not shown) by means of which, and through appropriate manipulation of the respective valves 124 and 126 in the lines attaching with theconnectors 119 and 122, the passage 42' can be utilized alternately as a means for supplying myocardial preservation solution and as a means for detecting the pressure in the aorta between the intervals during which the myocardial preservation solution is supplied and before or after the occluder is distended to measure the blood pressure in the ascending aorta.

As in the previous embodiment, theoccluder diaphragm 54 is attached to a second chordally extending plate, here indicated as 52', that is spaced from thefirst plate 116. Thediaphragm 54 communicates with a source of saline inflating liquid viainlet connection 128 that is connected to a manifold 58' via theinternal conductor 130 with conductors 56' interconnecting the manifold with openings 53' formed in the plate 52'. Similar to the previously described apparatus, the inflating fluid supply line connecting with the manifold 58' is desirably made common with theinlet connector 98 to thebelt cuff 96 in order that inflating fluid is delivered substantially simultaneously to both thediaphragm 54 and to the belt cuff in order to insure an equalization of the compression applied to the opposed surfaces of the blood vessel wall.

Theinterior region 132 of the trocar shell 20', exteriorly of the passages 42' and 56' formed by thepartition plates 52 and 116, defines a passage included in the blood circulating line between the patient and a heart-lung machine (not shown). To render such circulating flow effective, the trocar shell 20' is provided in thelower portion 110 on the side of the slots 66' opposite that containing the opening 48' with anelongated opening 134 that is sufficiently sized to accommodate blood flow from the heart-lung machine and return to the ascending aorta on the distal side of the expandedoccluder diaphragm 54, as hereinafter more fully described. Connection from the heart-lung machine to the end of the trocarupper portion 108 is made by means of a tubular feed line 136 (FIG. 14) that is fixedly attached to the shell by means of connectingelements 138 of well-known type on the exterior surface of the shell 20' which cooperate with complimentary elements in the line. Avalve mechanism 140 operated by actuatingknob 142 is effective to open and close the flow circulating line as further explained herein.

Extending axially of the shell 20' is the blade assembly, indicated generally byreference numeral 144. It includes a plurality of articulatedscalpel blades 146, here shown as being three in number disposed on 120° angular spacing but which may comprise a greater or lesser number of blades. Theblades 146 are arranged to be retractably extended from the opening 27' at the tip of thelower portion 110 of shell 20' whereby, when the trocar 12' is inserted by the surgeon longitudinally into the belt collar 88', the blades are effective to incise the wall of the aorta to permit penetration thereof by thelower portion 110 of the trocar apparatus.

Theblade assembly 144 comprises an axially disposedsupport rod 148, to the leading end of which each of the blades is attached by apivot connection 150 thereby forming a sharp point. At its upper end theblade support rod 148 contains an operatinghead 152 and aspacer flange 154 axially spaced therefrom.Support rod 148 is concentrically received in an axiallyelongated support sheath 156 for relative sliding movements there-between. Articulatinglinks 158 connect the rear ends of therespective blades 146 to the leading end ofsheath 156 by means ofpivot connections 160. An operatingflange 162 at the rear end of thesheath 156 effects movement of the sheath with respect to thesupport rod 148 whereby extension of the sheath downwardly causes therespective blades 146 to be angularly displaced outwardly into engagement with the shoulder 32' formed by the inturned flange 30' that defines the opening 27' at the lower end of the shell 20'.

Thesheath 156 is concentrically enclosed by anelongated carrier sleeve 164 having an operatingflange 166 at its rear end. The leading end of thecarrier sleeve 164 contains a plurality of circumferentially spacedcontainment slots 168 adapted to receive the respective articulatedlinks 158 andblades 146 when thesheath 156 is retracted into the carrier sleeve prior to withdrawal of theblade assembly 144 from the trocar 12'.

In order to properly position the elements of theblade assembly 144 prior to inserting the trocar 12' into the belt collar 88' the apparatus includes anapplicator cover 170, here shown as being a cylindrical shell having a closure plate 172 at the top and an interior integrated steppedsleeve 174 havinglands 176 and 178 adapted to engage the operatingflanges 162 and 166 on the rear ends of thesheath 156 andcarrier sleeve 164, respectively. The undersurface of the closure plate 172, as shown, provides the bearing surface for the operatingflange 152 on thesupport rod 148.

The lower end of theapplicator cover 170 is arranged to seatedly engage the upper surface 182 of a hollowcylindrical spacer 180. As shown, the opposed upper andlower surfaces 182 and 184, respectively, of thespacer 180 contain alignedaxial openings 186 and 188 to accommodate passage of theblade assembly 144. Thelower surface 184 of thespacer 180 engages the facing surface of the closure cap 26' to create a substantially rigid structure extending the full length of the assembled trocar apparatus.

The pressurizing belt 14' adapted for use with this embodiment of the apparatus is particularly illustrated in FIGS. 24 to 26. It comprises a base structure 86' having an upstanding collar 88', the latter containing a through-opening 90' for reception and passage of the trocar 12'. The base structure 86' is adapted to completely surround theaortic blood vessel 14 and for this reason contains ahinge 190 on one side of the collar 88' that divides the base into two wings, one of which 192 contains the collar and inflating fluid connector 98' and the other 194 of which has alocking detent 196 formed at its end for engagement with a cooperatingnotch 198 in the end ofwing 192. As in the previously-definedbelt structure 14 the undersurface of the base 86' attaches an expandable cuff 96', the interior of which fluidly connects via connector 98' with a source of inflating fluid (not shown).

The collar 88' differs from that in the previous embodiment of pressurizingbelt 14 in that the through-opening 90' is formed to accommodate downward reception of the trocar 12'. This opening 90' is also provided with a locking device, here shown as a bayonet-type connection 200, defined byopposed grooves 202 formed in the wall of the opening. Eachgroove 202 has an open upper end at 204 in the wall of the collar opening 90' and aseat 206 at the lower end thereof, whereby a pair of diametrallyopposed projections 208 on the exterior surface of theupper portion 108 of trocar 12' are caused to traverse the grooves as the trocar is projected into the belt collar 88' causing the trocar to undergo approximately 90° rotation about its longitudinal axis for ultimate seating in theseats 206 to effectively lock the trocar 12' with respect to the belt collar.

As shown in FIGS. 19 through 23, theprojections 208 are positioned diametrally on the external surface of the shell 20', with each being disposed in substantial alignment with theopenings 48 and 134, respectively. Thus, with theprojections 208 lockingly received in therespective bayonet seats 206, the slots 66' are positioned transversely of the blood vessel passage in order to render the diaphragm 54', when activated, effective to occlude flow through the passage.

The operation of this embodiment of the invention is as follows. Following incision of the chest cavity by the surgeon to expose the ascendingaorta 16 andheart muscle 18 and selection of the position along the aorta at which occlusion of the blood vessel will be effected, the pressurizing belt 14' is mounted to theblood vessel 16 by first spreading thewings 192 and 194 by means ofhinge 190 to permit reception of the belt around the blood vessel without distortion thereof and, thereafter, insertion of thedetent 196 into theslot 198 to lock the belt in surrounding relation to the aorta.

Next, the trocar 12', with thevalve 140 actuated to its open position and with theblade assembly 144,applicator cover 170 andspacer 180 in position is inserted into the opening 90' of the collar 88' of the pressurizing belt 14' by registering theprojections 208 on the exterior of the trocar shell 20' with the open ends 204 of theslots 202 of the bayonet connection 200. As theprojections 208 move along the vertical portions of therespective slots 202, theblades 146 incise the wall of the aorta whereby the trocar 12' is caused to penetrate into the interior of the aortic passage. The length of thelower portion 110 of the shell 20' is such that, when theshoulder 106 engages the aorta outer wall the tips of theblades 146 are slightly spaced from the aorta inner wall on the side opposite the incision. This spacing of the tips ofblades 146 from the opposite side of the aorta wall is further controlled by the cooperation between theprojections 208 and the bayonet seats 206 that prevents excessive penetration by the lower end of the trocar into the interior of the aorta.

Also, because theblades 146 produce a cut in the aorta wall of slightly smaller lateral extent than the outside diameter of thelower portion 110 of theshell 20, a snug fit between thetrocar 12 and the aorta wall is created and becauseclosure cap 26 contains a self-sealing septum seal through which theblade assembly 144 passes, blood flow through the trocar from the incised opening in the aorta wall is contained.

Following this, theapplicator cover 170 is removed, as shown in FIG. 22, to expose the rear end of theblade assembly 144, particularly the operating heads 152, 162 and 166 of the blade support red 148,sheath 156 andcarrier sleeve 164, respectively. With the supportred head 152 being held against retrograde movement, thehead 162 onsheath 156 is pulled upwardly to angularly constrict theblades 146. When thehead 162 abuts thespacer flange 154 on the support red 148 theblades 146 have been completely constricted and moved into thecontainment slots 168 in thecarrier sleeve 164. Next, thecarrier sleeve 164 is withdrawn from the trocar 12' by pulling on thehead 166 thereof.

An indicating mark (not shown) is provided on the exterior of thecarrier sleeve 164 and so positioned thereon as to indicate, when it appears immediately above thespacer 180, that the lower end of theblade assembly 144 is above thevalve 140. At this instant thevalve operator knob 142 is rotated to close the valve and, thereafter, thespacer 180 and closure cap 26' may be removed from the upper end of the trocar 12'.

When the upper end of the trocar is effectively open upon removal of cap 26', thevalve 140 may be opened briefly in order to back bleed the aorta and expel any air that may be entrained in the trocar. Upon again closing thevalve 140 theflow line 136 from the heart-lung machine is attached to the trocar by making the connection with the connectingelements 138.

Once the heart-lung machine is functional, blood is circulated through theflow line 136 and trocarinternal passage 132 for discharge from the trocar through theopening 134 on the distal side of the shell. Thereafter, inflating fluid in the form of pressurized saline liquid is admitted simultaneously to the pressurizing belt cuff 96' and to theoccluder diaphragm 54 by actuation ofcontrol valve 129. The flow of inflating liquid through the trocar 12' occurs in series through theinlet connection 128,internal conductor 130, manifold 58', conductors 56' andopenings 53 into the interior of thediaphragm 54. Upon inflating, thediaphragm 54 expands laterally, exiting the trocar through the slots 66' whereupon it enters theaortic passage 16 and expands such that thetoroidal cushion 62 is brought into occluding engagement with the interior surface of the passage wall. Simultaneous admission of saline liquid to the cuff 96' applies an equal pressure force to the external wall of the aorta in opposition to the force applied by thetoroidal cushion 62 of theoccluder diaphragm 54 whereby the aortic wall is acted upon by balanced forces to prevent its distention or collapse under the influence of the occluder diaphragm or belt cuff. In practice due to the relative flow areas presented to the inflating liquid by the trocar 12' and pressurizing belt 14', respectively, the belt cuff 96' will desirably become pressurized slightly prior in point of time from pressurization of theoccluder diaphragm 54.

It will be appreciated that, by so-maintaining the aortic wall, the passage can be effectively occluded without disrupting the wall and without creating the attendant danger of its rupturing or of dislodging material therefrom which could cause serious morbidity or even death to the patient. In occluding the aortic passage its proximal side is rendered quiet and bloodless where the surgery can be performed safely.

Following completion of the surgical procedures requiring occlusion of the aortic passage thediaphragm 54 and cuff 96' are deflated simultaneously by the release of the inflating saline liquid from the interiors of these members by openingvalve 129. Desirably a negative pressure may be applied in the fluid line communicating with the manifold 58', conductors 56' and diaphragm interior whereupon the diaphragm is positively induced to collapse so that the trocar 12' can be efficaciously removed from the aorta.

Practice of the invention, furthermore, permits, via a single incision made in the aortic wall, a multitude of ancillary procedures to be performed. For example, by operation of control valve 124 myocardial preservation solution can be periodically admitted to the root of theaorta 16 to arrest and preserve theheart muscle 18 thus to render it more quiet and motionless so that cardiac surgery can be performed more effectively. As will be appreciated from consideration of FIG. 17, this is accomplished by the opening of control valve 124 whereby myocardial preservation liquid enters the trocar 12' throughinlet connection 118 and flows seriatim through theelbow 120 and passage 42' before exiting the trocar to the proximal side thereof via the discharge opening 48'.

Also, by provision of a fluid line 121 containing control valve 126 communicating with passage 42' viaconnection 122 and extending to a pressure gauging device (not shown), the pressure in the aorta can be effectively monitored during application of myocardial preservation solution to permit determination of proper and complete distribution of the solution throughout the coronary tree. In addition, when thediaphragm 54 is deflated, this fluid line can be employed to monitor standard systematic pressure.

The fluid passage 42' and opening 48' in the shell wall are further operable for the extraction of fluid from the aorta root and the heart. For example, during the period of aortic occlusion, and when the myocardial preservation solution system is inactive, in order to keep the ascending aorta and heart collapsed and free of blood, a negative pressure can be applied to the passage 42' by appropriate connection of theline 119 to a negative pressure source and the system employed for the removal of blood from the heart and from the aorta root.

Similarly, this same fluid conducting system can also be employed as a means for venting air from the heart and the ascending aorta following completion of the surgical procedure on the heart when the occludingdiaphragm 54 has been collapsed so as to remove the flow obstruction from the aortic passage. During this period, when the patient remains on the heart-lung machine and before the blood-ejecting function is returned to the heart, it is necessary to insure that all air bubbles are removed from the heart chambers. This is commonly achieved through use of a vent placed in the left atrium or left ventricle. Upon clamping of this vent to permit filling of the left ventricle and ejection of blood by the heart into the ascending aorta, it is desirable, as an added precaution, to vent an amount of blood from the ascending aorta to insure the evacuation of any micro air bubbles entrained in the blood before they can be dispersed into the cerebral circulation thereby to prevent the danger of possible stroke.

Use of the trocar 12' for the performance of this function is particularly advantageous due in part to the disposition of the opening 48' closely adjacent the upper portion of the aortic wall whereby air can readily migrate into the opening for extraction via passage 42' and the line fromconnector 119 that, during occlusion of the aorta is used to conduct myocardial solution. Importantly, air extraction in the manner described is enhanced by the protrusion of the trocar 12' into the aorta passage whereby turbulence in the blood flow stream is created. Also, the presence of the deflateddiaphragm 54 in the aortic passage creates a restriction tending to retard blood flow and thereby facilitate air removal by enhancing the ability of the air bubbles to migrate to the upper region of the blood flow stream from whence they can be extracted by induction through the opening 48'.

It should be understood that, although preferred embodiments of the invention have been illustrated and described herein, changes and modifications can be made in the described arrangements without departing from the scope of the claims appended hereto.

Claims (21)

I claim:

1. An occluder apparatus for obstructing the flow of blood in a blood vessel comprising, in combination:

an inflatable diaphragm carried by a diaphragm insertion body in a deflated condition into the interior of said blood vessel for expansion under the influence of fluid pressure into engagement with the interior wall of said blood vessel about substantially the full circumference thereof;

a belt-like pressurizing device adapted to receive said body comprising an inflatable cuff arranged to substantially surround the exterior of said blood vessel, said cuff being expandable under the influence of fluid pressure into engagement with the exterior wall of said blood vessel in substantially opposing relation to said diaphragm when expanded;

means for inflating said diaphragm; and

means for inflating said cuff.

2. The combination according to claim 1 in which said diaphragm-inflating means and said cuff-inflating means are fluidly interconnected for the substantially simultaneous admission of pressurizing fluid to said diaphragm and said cuff.

3. The combination according to claim 1 in which said belt-like pressurizing device comprises a base adapted to enclose the exterior of said blood vessel; means for attaching said cuff to said base; and inflating fluid inlet means formed on said base and connecting with said cuff to supply the interior thereof with pressurizing fluid.

4. An occluder apparatus for obstructing the flow of blood in a blood vessel comprising, in combination:

an elongated hollow tubular body having a leading end for reception in said blood vessel;

means for inserting said body through the wall of said blood vessel to extend said leading end into the interior of said blood vessel;

an inflatable diaphragm carried by said body in a collapsed, deflated condition for insertion into the interior of said blood vessel;

means for inflating said diaphragm to expand it about its periphery into cushioned occluding engagement with the interior wall of said blood vessel;

a belt-like pressurizing device including an inflatable cuff arranged to substantially surround the exterior of said blood vessel and to be expanded under the influence of fluid pressure into engagement with the exterior wall thereof in substantially opposing relation to the engagement of said interior wall of said blood vessel by said diaphragm; and

means for inflating said cuff.

5. The combination according to claim 4 in which said diaphragm-inflating means and said cuff-inflating means are fluidly interconnected for the admission of pressurizing fluid for the substantial simultaneous inflating of said diaphragm and said cuff.

6. The combination according to claim 5 in which said belt-like pressurizing device comprises:

a base adapted to enclose the exterior of said blood vessel;

means for attaching said cuff to the wall-facing surface of said base;

inflating-fluid inlet means formed on said base in fluid communication with the interior of said cuff for supplying pressurizing fluid thereto; and

means on said base retaining said tubular body.

7. The combination according to claim 6 in which said retaining means comprises a substantially annular collar extending from the exterior surface of said base; and means forming an opening extending through said collar and said cuff to receive said tubular body.

8. The combination according to claim 7 including at least one locking projection extending from said tubular body; and means on said collar cooperable with said projection for fixedly retaining said tubular body.

9. The combination according to claim 8 including means on the exterior of said tubular body for receiving sutures to fix said body to said blood vessel; and said locking projection on said tubular body engaging a cooperating recess in said collar when said belt is superimposed on said body.

10. The combination according to claim 8 including a bayonet slot formed on the interior surface of said collar, said bayonet slot cooperating with said locking projection upon applying said tubular body to said collar for locking said tubular body with respect to said collar.

11. The combination according to claim 8 including piercing means disposed at the leading end of said tubular body for incising the wall of said blood vessel upon extending said tubular body through said collar.

12. The occluder apparatus according to claim 4 in which said diaphragm release-enabling means comprises elongated opening means extending longitudinally of said body.

13. The occluder apparatus according to claim 12 including means forming a partition extending transversely of the interior of said body defining longitudinal fluid-conducting passage means therein; and means forming fluid openings in the wall of said body to place said passage means in fluid communication with the exterior of said body.

14. The occluder apparatus according to claim 13 in which said fluid passage means includes means at an end opposite said wall openings connecting said passage means with at least one fluid source exteriorly of said body.

15. The occluder apparatus according to claim 14 in which said passage means connects at said end with a heart-lung machine for circulating blood to said blood vessel on a side of said diaphragm.

16. The occluder apparatus according to claim 15 including valve means in said passage means for selectively admitting blood supply from heart-lung machine to said passage means.

17. The occluder apparatus according to claim 15 in which said partition means comprises a partition plate extending chordally across the interior of said tubular body to divide said interior into parallel longitudinally-extending fluid-conducting passages; first opening-forming means in the wall of said body on one side of said diaphragm release-enabling means for fluidly communicating one of said passages with said blood vessel on the proximal side of said diaphragm and second opening-forming means in the wall of said body on the other side of said diaphragm release-enabling means for fluidly connecting the other of said passages with said blood vessel on the distal side of said diaphragm.

18. The occluder apparatus according to claim 17 including means at an end of said one passage for connecting said one passage to a source of myocardial fluid and to a pressure monitor, and valve means operable with said connecting means for connecting said passage to said source of myocardial fluid and to said pressure monitor.

19. The occluder apparatus according to claim 18 including means at an end of said other passage for connecting said other passage to a heart-lung machine; and vlave means in said other passage for selectively circulating blood from said heart-lunch machine to said blood vessel on the distal side of said diaphragm.

20. The occluder apparatus according to claim 17 means at an end of said other passage for connecting said other passage to a heart-lung machine to circular blood from said heart-lung machine to said blood vessel on the distal side of said diaphragm.

21. The occluder apparatus according to claim 20 valve means in said other passage for selectively circulating blood from said heart-lung machine to said blood vessel on the distal side of said diaphragm.

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